Download Dry Eye Questionnaire

DRY EYE QUESTIONNAIRE
Patient Name or ID:
Date:
Technician:
Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease?
Y
N
When?
Do you have any of the following symptoms?
Blurry vision
Redness
Burning
Itching
Light sensitivity
Excess tearing/ watering eyes
Tired eyes, eye fatigue
Stringy mucus in or around the eyes
Foreign body sensation
Contact lens discomfort
Scratchy feeling of sand or grit in the eye
Have you had any of the following surgeries?
Cataract:
Y
N
Glaucoma:
Y
N
Refractive Surgery:
Y
N
Do you use?
Contact lenses
OTC eye drops such as artificial tears
Rx eye drops for Dry Eye Syndrome (e.g., Restasis)
Rx eye drops for Glaucoma (e.g., Xalatan, Timolol)
Rx eye drops for Allergy (e.g., anti-inflammatory, antihistamine)
Nutritional supplements (e.g., flaxseed oil, omega-3)
Are your symptoms related to the following environmental conditions?
Windy conditions
Places with low humidity (e.g., airplanes/hospital)
Areas that are air conditioned/heated
Are you taking any of the following medications?
Antihistamines/decongestants
Antidepressant or anti-anxiety
Oral corticosteroids
Hormone replacement therapy or estrogen
Antihypertensives (e.g. diuretic, beta-blocker)
Accutane or other oral treatment for acne
Have you ever had punctal occlusion?
Y
N
If the information provided in this form, in conjunction with other clinical data, raises the suspicion of
Dry Eye Disease, then obtaining a Tear Osmolarity Test may be indicated.
I reviewed this form and based on the information contained therein and other available clinical data,
I suspect that this patient has Dry Eye Disease and obtaining a tear osmolarity measurement is
medically necessary for the diagnosis and management of this patient’s ocular problem(s).
Attending Clinician:
Date:
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